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Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: 4-8 Medicaid eligibility. If information and/or documentation submitted by the family at the time of application suggest that the family is eligible for Medicaid, the health plan must refer the family to a facilitated enroller or appropriate LDSS office to complete an application for Medicaid. If the health plan is a facilitated enroller, they can assist the family in completing the Access NY application, satisfy the face-to-face interview for Medicaid and submit the completed application and required documentation to the appropriate LDSS for a Medicaid eligibility determination. If the health plan is not a facilitated enroller, they are required to forward the application and documentation to the LDSS office and provide families with information regarding the location of facilitated enrollers and the LDSS offices where families can apply for Medicaid.

Facilitated enrollers are located in communities and are available nights and weekends to assist families in completing the Access NY application. Children who are found ineligible for Medicaid based on the screen, may apply and be enrolled in CHPlus, if otherwise eligible. Documentation of these referrals is required and reviewed at the time of the audit.

The following chart identifies the Medicaid income levels for pregnant women and children:

Individual / Age

Net Family Income (Federal Poverty Level %)

Pregnant women

<=200% FPL, without an asset test

Children <1

<=200% FPL, without an asset test

Children <6

<=133% FPL, without an asset test

Children 6 – 18

<=100% FPL, without an asset test

4.4.3. The State is taking steps to assist in the enrollment in CHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2) (42CFR 431.636(b)(4))

The use of one application for both children’s health insurance programs (CHPlus and Medicaid) facilitates enrollment into the correct program. All children are first screened for Medicaid eligibility. The applications for those children found ineligible for Medicaid are sent to the health plan chosen by the family for enrollment in CHPlus.

Children recertifying for Medicaid, that are found eligible for CHPlus, do not need to complete a new application to enroll in CHPlus. The State will receive electronic files from Medicaid on a weekly basis, indicating those children that appear CHPlus eligible at recertification. Children enrolled in a Medicaid managed care plan that is also a CHPlus plan will be transferred to that plan. If the child is enrolled in a Medicaid Managed Care plan that is not a CHPlus plan, the state will auto-assign the child to a CHPlus health plan. For a child enrolled in fee-for-service Medicaid, the child will be auto-assigned to a plan or in cases where there is only one CHPlus plan in a county, the State will forward the names of those children to that plan.

The health plans will confirm CHPlus eligibility by contacting the families about the presence of other health insurance, access to state health benefits, and to collect any premium contribution that may be owed. Health plans shall not enroll these children in CHPlus presumptively. Once a child is successfully transferred and enrolled in